Independent physician practice survival: A doctor's story [Q&A]

Some industry experts think independent physician practices are about to go the way of the dinosaur and eight track tapes. Recent studies say only 1 in 3 will remain in private practice by the end of 2016. But if they were once on the brink of extinction, independent practices are making a comeback.

New alternative payment models are helping physician practices remain profitable--and independent--in the current healthcare landscape. Patient-centered medical homes, physician-led accountable care organizations and other alternative payment models now offered to encourage value-driven healthcare help practices and physicians like Mark Miller, M.D., preserve their autonomy.

Miller, 48, pictured right, specializes in family medicine and runs Tru Health Family Care, in Fayetteville, Arkansas, which celebrated its 10th anniversary last December. He is a solo practitioner, who runs his clinic with help from a physician assistant and nurse practitioner. He spends 80 percent of his time at his clinic and the other 20 percent as the medical director for three nursing homes.

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In an exclusive interview with FiercePracticeManagement, Miller talks about how he's overcome obstacles that stand in the way of practices staying independent and offers advice on how other solo practitioners can do the same.

This interview has been edited for clarity and length.

FiercePracticeManagement: With so many physicians choosing to become employees of hospitals and healthcare systems, why do you like being independent?

Miller: I like making my own decisions. I enjoy not having to go through some committee at a hospital and taking six months to get another otoscope. I like being able to--if I can afford to pay for it--put what I want in my clinic. For instance, I can build up a cosmetic practice if I want. When you work for a hospital and have nurse practitioners and physician assistants that work underneath you, they pay you a certain amount of money to oversee them, but they won't actually let you employ them and profit from their work. So it usually ends up being more profitable in the long run to be an independent family doctor, rather than working for an hourly sum or a salary. You take on more responsibility, more work, more trouble, more headaches, but you are also able to profit from that. I like forging my own way, making my own clinic and having my own name out there.

FPM: What is your biggest challenges that other independent practices are also likely to face?

Miller: The single biggest challenge going forward will be contracting with insurers to be able to see their patients. Unless you are part of a big group, those contractual relationships are difficult to get and to manage.

FPM: How can practices overcome that?

Miller: One way I have been able to overcome that is through participation in an accountable care organization. Locally, one of the three hospital systems here, Northwest Health System, which is part of Community Health Systems, a large national hospital group, has a pretty open-minded and forward-thinking CEO. They have formed a clinically integrated network (CIN) that combines employed physicians and local independent physicians into one group for contractual purposes, and for quality improvement and quality reporting. I was fortunate enough to be nominated to the board of directors of that group, and so I participate in networking. That's going to help me going forward on multiple levels.

FPM: As healthcare continues to move to a value-based system, is that something doctors are going to have to do to stay independent?

Miller: Going forward it's probably going to be important. You don't have to [be part of a larger group] right now because you can still see patients covered by Medicare, those who pay cash, or are covered by regular insurance. But I think the landscape is changing, that eventually you are going to have to have associations with larger groups to be able to report quality data in order to be able see those patients. Insurers are not going to want doctors to be on their panels who cannot prove that they take good care of patients. The problem is you have to have a large, pooled group of providers to be a reasonable sample size for quality reporting.

FPM: How should doctors think about the changes that are taking place in the way they get paid?

Miller: I look at the clinically integrated network as something that is going to benefit me. As a provider who cares more about the quality of care than the quantity of patients I see, I think I am going to start getting paid better for my panel of patients. Instead of getting paid a fee for service, I'll start getting paid for the quality of care I provide, essentially sharing in the savings for the network. I think being part of the clinically integrated network is going to be a big deal for me going forward. I'll get to be part of the initial process of planning and implementing this CIN.

FPM: Are there other challenges that come into play for independent practices?

Miller: There are always call schedules. You have to take 24/7 calls for your patients. You have to have a good call group that is typically shared between providers. Another challenge is training your staff on regulations such as HIPAA and OSHA compliance.

FPM: It seems like a major frustration for many doctors is the use of electronic medical records. Has that been a frustration for you?

Miller: That's been going on for probably close to 15 years. I was one of the first providers in the area to use electronic records. I feel pretty much on the cutting edge of that. There's a lot of power to computers and I think as time goes on, especially with quality reporting, physicians will understand the importance of computers in improving quality. That will be the key principle that drives the use of electronic records.

FPM: Another big complaint of many doctors is the increasing amount of paperwork they face, which means less time to spend with patients. Is that a worry for you?

Miller: No, because we want our patients to be well taken care of. You can't do that seeing them for five minutes. We see about 30 to 50 patients a day among our 2 to 3 providers. We don't like to rush patients through. We want to spend time seeing our patients. We want them to be happy and think we are the best clinic they have ever been a part of. Then they'll tell their friends and family that we care about people. I think customer service is important. For instance, we personally call our patients with their labs and we don't let computers do that. We're used to taking care of our people and I think that's important in this day and age. People appreciate that. We have elderly patients with whom we take extra time. To me, being a doctor is not all about making money; you have to enjoy what you do--providing a good service for people.

FPM: Are there ways you have found to be cost-effective and keep practice expenses down?

Miller: One thing I do is sublease office space to a therapist. I also have someone in my practice who does cosmetic procedures, such as Botox and laser therapy. If you work for a large corporation, they usually don't let you do those kinds of things. Those have been kind of fun. One of the biggest things you can do in my opinion is to diversify. I have a clinic and a nursing home practice. If one of the two suffers, I can always lean back on the other. If the insurance part of it goes south, I have a cosmetic practice I can do.

FPM: Some practices are struggling. Have you been able to maintain your practice income?

Miller: Mainly because we reduced expenses and we have been able to increase our flow of patients. I'm probably a little different than other people. Being independent you can profit more from your business. I'm not a greedy person. I'm going to be happy with what I make.

FPM: Do you have any advice for other physician practices that are trying to survive and remain independent?

Miller: I think it's important to look for opportunities to work within a group and to make yourself available to serve on boards or help assist in forming accountable care organizations and being part of that leadership. We're in the minority as independent people are but I think these groups do want independent practice physicians to be part of their networks. So we'll probably have more of an opportunity to have a say from an administrative perspective. I would encourage people to get involved. When you do get involved, then you understand the components that are important to making practices profitable. That is going to be quality reporting going forward. Immerse yourself in the quality of your practice, otherwise I think it is suicide.

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